Health inspection·July 17, 2024

F689 Code of Federal Regulations, Title 42, Section 483.25 (d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72311. Nursing Service - General (a)Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 6/4/2024, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey. As a result of the investigation, The CDPH determined the facility failed to ensure an environment free of accident hazards for Residents 8 and 36 who were smokers by failing to: 1. Implement the facility's smoking policy titled, "Smoking Policy-Residents," for Residents 8 and 36 who did not have smoking privileges to smoke with staff supervision, and for staff to keep Residents 8 and 36's smoking articles including cigarettes and cigarette lighters for Residents 8 and 36. 2. Implement the facility's smoking policy titled, "Smoking Policy-Residents," to evaluate Resident 8's ability to smoke safely with the consultation from the facility's Director of Nursing (DON) and Resident 8's Attending Physician when safety restriction for smoking was needed in accordance with facility's "Safe Smoking Evaluation Form." 3. Implement the facility's smoking policy titled, "Smoking Policy-Residents," not to allow Resident 36 smoked in an area with an oxygen machine present in Resident 36's room. 4. Implement Resident 36's untitled care plan dated 5/25/2024 indicating not to allow Resident 36 to have cigarettes and lighters on her possession, and for Resident 36 to dispose cigarettes in the proper receptacle. 5. Implement Resident 36's smoking intervention in Resident 36's Smoking Evaluation (SE) form, dated 3/27/2024 indicating Resident 36 had poor vision and required supervision when smoking. These violations placed an accident hazard to all residents, staff and visitors that could affect their health, safety, and wellbeing. a. A review of Resident 8's Admission Record indicated the facility admitted Resident 8 on 8/6/2019 and readmitted on 6/3/2024 with diagnoses that included diabetes mellitus, nicotine dependence and paranoid schizophrenia. A review of Resident 8's Nurses Notes dated 5/22/2024, timed 7:46 pm, indicated Resident 8 was transferred to General Acute Care Hospital 1 emergency room on a 5150-hold due to confusion, agitation, wanting to commit suicide, threatening to kill the DON and threatening to blow up the hospital. A review of Resident 8's Order Summary Report dated 6/3/2024 indicated for licensed staff to administer Seroquel 100 milligrams, one tablet in the morning, and three tablets at bedtime by mouth, daily for paranoid schizophrenia to Resident 8, as manifested by hearing voices telling Resident 8 to hurt himself and others. A review of Resident 8's Medication Administration Record dated 6/3/2024 through 6/10/2024 indicated Resident 8 received Seroquel 100 mg one tablet at 9 a.m., and three tablets at 10 p.m. by mouth every day from 6/3/2024 through 6/10/2024. During a concurrent observation and interview on 6/4/2024 at 10:58 am, Resident 8 stated he just came back from a smoke break in the patio. Resident 8 stated he smoked in the patio by himself without staff supervision. Resident 8 had one opened pack of cigarette with 17 cigarettes, three disposable lighters on Resident 8's bedside table, and three unopened packs of cigarettes in Resident 8's cabinet drawer. Resident 8 demonstrated the three cigarette lighters were working. Resident 8 stated he was a smoker and consumed 20 cigarettes per day. Resident 8 stated staff gave him the cigarettes and lighters so he could smoke anytime without asking for the cigarettes and lighters from staff. Resident 8 stated he had been smoking without staff supervision. During a concurrent observation and interview with the DON in Resident 8's room on 6/4/2024 at 11:02 am, the DON stated she did not know why Resident 8 had four packs of cigarettes with three disposables lighters in Resident 8's room. The DON stated Resident 8 had not been evaluated for safe smoking and had no plan of care to address smoking when she checked Resident 8's medical record "at around 10 am this morning." The DON stated Resident 8 should not be in possession of cigarettes and lighters because "it was an accident hazard." The DON stated the lighter could cause burns to Resident 8 or cause fire in the facility. The DON stated Resident 8 could not smoke without staff supervision due to Resident 8's behavior of hearing voices telling him to hurt himself and others in the facility. During an interview with the Social Services Director (SSD), and concurrent review of Resident 8's SE form, dated 6/4/2024, on 6/4/2024 at 2 pm, Resident 8's SE form indicated Resident 8 was not safe to have cigarette lighter in Resident 8's room and Resident 8 needed to be supervised by staff during smoke break. The SSD stated she was responsible for evaluation for all smokers, including Resident 8 in the facility. The SSD stated Resident 8 should not have cigarettes and lighter in Resident 8's possession and should be supervised by staff when smoking. The SSD stated she has not completed the SE for Resident 8 until this morning around 11:43 am after she was informed by the DON that Resident 8 had cigarettes and lighters in his possession in his room. b. A review of Resident 36's Admission Record indicated the facility admitted Resident 36 on 3/18/2023 with diagnoses that included nicotine dependence and depression. A review of Resident 36’s untitled care plan dated 3/31/2023 indicated Resident 36 had impaired visual function related to aging process. The care plan interventions included for staff to alert Resident 36 to changes in the environment. A review of Resident 36's untitled care plan dated 2/27/2024, indicated Resident 36 was at risk for a smoking related injury due to noncompliant behavior with smoking hours and designated areas. The care plan goal was for Resident 36 to smoke with staff supervision. The care plan interventions included for staff to accompany Resident 36 to smoke in the designated area, observe the resident during smoking hours, set limits with noncompliant behavior, and to monitor Resident 36 in safe handling and disposing of cigarette butts and ashes. A review of Resident 36's Minimum Data Set (MDS) dated 3/25/2024 indicated Resident 36 had intact cognition. The MDS indicated Resident 36 used a walker and wheelchair for ambulation and required supervision with walking for 10 feet. The MDS indicated Resident 36 required partial/moderate assistance for oral hygiene, toileting, and personal hygiene. A review of Resident 36’s SE form dated 3/27/2024 at 9:27 am indicated Resident 36 had poor vision and required supervision when smoking. A review of Resident 36's History and Physical dated 4/10/2024 indicated Resident 36 had the capacity to understand and make decisions. A review of Resident 36's untitled care plan dated 5/25/2024 indicated Resident 36 was a smoker. The care plan goal indicated for Resident 36 not to smoke without supervision. The care plan interventions included for staff to educate Resident 36 on proper disposal of cigarettes after smoking, explain the purpose of supervision for safety, and instruct Resident 36 that cigarettes and lighters were not allowed in Resident 36's possession. During an interview on 6/4/2024 at 10:46 am with the Assistant Administrator (AADM), the AADM stated there were no designated smoking times because all residents who smoke were alert and oriented. During a concurrent observation and interview on 6/4/2024 at 11:01 am with Resident 36 in the patio, Resident 36 was sitting in a chair, alone and unsupervised, next to a sliding glass door that was connected to Resident 36's room. Resident 36 placed a black cigarette pack into the basket of the front wheeled walker that was in front of Resident 36. Resident 36 stated Resident 36 "just finished smoking" in the patio and stated Resident 36 kept the cigarettes and lighters in Resident 36's possession for over a year. Resident 36 stated staff never supervised Resident 36 when Resident 36 smoked. Resident 36 stated Resident 36 had extra cigarette lighters in Resident 36's room in a tin container. Resident 36 stated Resident 36's roommate had an oxygen machine in Resident 36's room. Resident 36 stated Resident 36 was legally blind. Resident 36 stated Resident 36 had difficulty using the ashtrays in the patio. Resident 36 stated Resident 36 placed cigarette butts inside a plastic bottle and threw the bottle in the trash can in the resident's bedroom when Resident 36 filled the bottle with cigarette butts. During a concurrent observation and interview on 6/4/2024 at 11:15 am with Registered Nurse Supervisor 1 (RN Sup 1) in Resident 36's room, an oxygen machine was next to Resident 36's roommate bed. A sign was posted outside Resident 36's door with red text that indicated "Danger, Oxygen, No Smoking, No Open Flame." RN Sup 1 stated there was an oxygen machine in Resident 36's room and a "Danger Sign" was posted outside Resident 36's room. RN Sup 1 stated Resident 36 would smoke alone, outside in the patio in front of Resident 36's room. RN Sup 1 stated RN Sup 1 was unsure if Resident 36 could keep cigarettes and cigarette lighters at Resident 36's bedside. RN sup 1 stated RN sup 1 was unaware if Resident 36 could smoke unsupervised. During a concurrent interview and record review on 6/4/2024 at 11:16 am with RN Sup 1, Resident 36's untitled care plan dated 5/25/2024 was reviewed. The care plan indicated Resident 36 required supervision during smoking and staff to instruct and educate Resident 36 that cigarettes and lighters were not allowed in Resident 36's possession. RN Sup 1 stated it was a fire hazard having a lighter at Resident 36's bedside or in Resident 36's possession because Resident 36's roommate had an oxygen machine in the room. RN Sup 1 stated Resident 36 needed supervision during smoking according to Resident 36's CP. RN Sup 1 stated Resident 36 needed to use the ashtray that was provided in the patio because the plastic bottle could catch fire when the cigarette butt was not extinguished completely. During a concurrent observation and interview on 6/4/2024 on 11:36 am with CNA 4 in Resident 36's room, there were seven disposable lighters, one unopened cigarette pack and one opened cigarette pack with two and half cigarettes in the box. CNA 4 stated all seven disposable lighters were functional. CNA 4 stated CNA 4 was unsure when Resident 36 got the seven lighters and kept them in Resident 36's room. During an interview on 6/4/2024 at 4:56 pm with the DON, the DON stated cigarette lighters should not be at Resident 36's bedside especially when there was an oxygen machine in Resident 36's room because "it could cause an explosion or fire". The DON stated staff needed to remove the lighters immediately from Resident 36 for Resident 36 and other residents' safety. The DON stated Resident 36 needed supervision during smoking according to Resident 36's CP and SE form. The DON stated Resident 36's safety would be at risk when staff did not provide supervision during smoking. The DON stated residents who smoke needed to use the ashtrays to dispose cigarette butts appropriately. The DON stated cigarette butts should not be placed inside of a used plastic bottle because "it could cause fire when cigarette butts were not extinguished completely". A review of the facility's undated Policy and Procedure (P&P) titled, "Smoking Policy-Residents," indicated "Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc." The P&P indicated "Ashtrays are emptied into designated receptacles and the use of oxygen is prohibited in smoking areas." The P&P indicated "Residents who smoked needed to be evaluated on admission to determine if the residents had the ability to smoke safety with or without supervision." The P&P indicated "Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking." The P&P further indicated "Staff should consult with the attending physician and DON to determine if safety restrictions was needed on the residents' smoking privileges based on Safe Smoking Evaluation." The facility failed to ensure residents had an environment free of accident hazards for Residents 8 and 36 who were smokers by failing to: 1. Implement the facility's smoking policy titled, "Smoking Policy-Residents," for Residents 8 and 36 who did not have smoking privileges to smoke with staff supervision, and for staff to keep Residents 8 and 36's smoking articles including cigarettes and cigarette lighters for Residents 8 and 36. 2. Implement the facility's smoking policy titled, "Smoking Policy-Residents," to evaluate Resident 8's ability to smoke safely with the consultation from the facility's DON and Resident 8's Attending Physician when safety restriction for smoking was needed in accordance with facility's "Safe Smoking Evaluation Form." 3. Implement the facility's smoking policy titled, "Smoking Policy-Residents," not to allow Resident 36 smoked in an area with an oxygen machine present in Resident 36's room. 4. Implement Resident 36's untitled care plan dated 5/25/2024 indicating not to allow Resident 36 to have cigarettes and lighters on her possession, and for Resident 36 to dispose cigarettes in the proper receptacle. 5. Implement Resident 36's smoking intervention in Resident 36's SE form, dated 3/27/2024 indicating Resident 36 had poor vision and required supervision when smoking. These violations placed an accident hazard to all residents, staff and visitors that could affect their health, safety, and wellbeing. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of all staff, residents, and visitors.